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    PRESENTER : Kobinathan (090100452)Elveena Muthiriar (090100380)

    SUPERVISOR : Dr. Hj.Bugis Mardina Lubis, Sp A (K)

    DEPARTEMENT OF PEDIATRICSMEDICAL FACULTY OF

    UNIVERSITY OF NORTH SUMATERAM E D A N

    2 0 13

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    Staphylococcal scalded skin syndrome (SSSS) is theclinical term used for a spectrum of blistering skin

    diseases

    induced by the exfoliative (epidermolytic) toxins (ET)

    usually group II Staphylococci (phage type 3A, 3B, 3C,55 or 71)

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    Overall incidence is higher in developing countries

    Exfoliative skin disease is rare in neonates.

    The incidence rate is estimated to be 1 to 1.4 cases per millioninhabitants per year.

    The male to female ratio of SSSS disease was 5:1

    Whereas 2 cases of staphylococcal scalded-skin syndrome(SSSS) in five years later in neonates at Dr Soetomo Hospital,Surabaya, Indonesia from January 2001-January 2006.

    Case studyin

    Indonesia

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    Etiology

    S aureus(severaltypes) leads to release

    of exotoxin

    TypeA

    TypeB

    separation ofthe epidermisbeneath thegranular cell

    layer

    Spread-person to person via towels-droplets from either coughing or sneezing

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    fever

    erythema initially with formation of large superficiallocalized blisters to generalized exfoliation of the

    whole body. They form large superficial thin formed bullae which

    rupture and leave denuded skin behind after oozingfluid which varies from thin, serous liquid to purulent

    pus.

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    initial infection occurs

    Epidermolytic toxins are produced

    red rash and separation of the epidermis beneath thegranular cell layer

    Bullae form, and diffuse sheetlike desquamation occurs

    localized form

    only patchyinvolvement of theepidermis

    generalized form,in whichsignificant areas ofare involved,remote from theinitial site ofinfection

    Pathophysiology

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    The diagnosis may be clear from the appearance of the

    skin. Surface fluid or pus may be sampled (via a skin swab)

    to confirm the presence of the bacteria and in somecases blood will also be tested for infection.

    A small piece of skin may be sent for microscopicexamination

    (The British Association Of Dermatologists, 2009).

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    Neonates should be isolated and the skin lesion mustbe treated with care like burn wounds.

    It responds very well to antibiotic therapy

    Oral antibiotics effective against penicillin-resistantstaphylococcus can be used as well.

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    CASE REPORT

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    Name : DL

    Age : 16 years 8 months

    Sex : Female

    Date of Admission : September, 26th 2013

    Main Complaint :Blisters surrounding lips.History :Baby A was admitted in Perinatology, 2 bours later red colored rashes was formed on upperlips of patient. Then this patch develops fluid blister and white membrane formed on lower lips. The following day bulla was

    formed on the hand, leg and abdomen. The lesion spread to the hand, leg and abdomen. Within 2 days almost of his body

    was affected. Some of the blisters had ruptured, there was desquamation of the skin, and large, fragile, the blisters easily

    ruptured on the slightest pressure.

    Baby A born on 23rdOctober 2013 at 16.42 pm with cesarian operation with indication of severe preeclampsia

    with Impending Eclampsia + AG + KDR + PK + AH + B Inpartus. Birth weight: 3100 gram, Birth length: 50cm, AS : 8/9. Babywas born and cried spontaneously. Baby was cleaned with 3 clothes, baby was dried and warmed and positioned, airway

    clearance was done, tactile stimuli was done and the baby cried loud immediately, clamping, cutting and wrapping the

    umbilical cord was done with the aid of steril gauze.

    Immunization : incomplete

    History of previous illness: -

    History of previous medications:-

    History of feeding : from birth to 11thday : breast milk only

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    Physical Examination

    Body weight : 3.1kgHeight : 50cm

    Presens statusSens:Compos Mentis, Body temperature: 37.6 oC, Pulse: 140 bpm, Respiratory Rate: 48 bpm.

    Localized status

    Head :Fontanel is wide open. Head circumference: 35 cmEye :Light reflexes(+/+), isochoric pupil, conjunctiva palpebra inferior anemia

    (+/+), icteric (-/-) , Ear : Normal appereance ,Mouth :Bula found 1cm containing

    water on lips,white membrane formed on lower lips , Nose: Normal appereance.Thorax: Symmetrical fusiformis. Epigastria retraction (-). HR: 140 bpm, reguler,

    RR: 48 bpm, reguler. Crackles (-/-).Abdomen: Soepel, Peristaltic(+)N. Liver/Spleen/Renal :not palpable,

    Extremities: Pulse 140 bpm, regular, adequate pressure and volume, warm acral,

    CRT

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    Complete blood count(CBC)Hemoglobin (HGB) g% 13.9 13.4-19.8Eritrosit (RBC) 106/ mm3 4.13 5.33-5.47Leukosit (WBC) 103/ mm3 8.73 6.02- 17.5Hematokrit % 38.4 51 65Trombosit (PLT) 103/ mm3 88 217-497MCV fL 93 104-116MCH Pg 33.70 35-39MCHC g%

    36.20 32-34RDW % 19.10 14.9 18.7WBC CountNeutrofil % 50.80 37 80Limfosit % 27.40 20 40Monosit % 15.90 2 8Eosinofil

    %

    5.20 1 6

    Basofil % 0.70 0 1Neutrofil Absolut 103/L 4.44 5.5 - 18.3Limfosit Absolut 103/L 2.39 2.8 - 9.3Monosit Absolut 103/L 1.39 0.5 - 1.7Eosinofil Absolut 103/L 0.45 0.02 - 0.70Basofil Absolut 103/L 0.06 0.1 - 0.2

    Laboratory Result:September,26th 2013

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    Liver

    Billirubin total Mg/dl 8.41

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    Differential DiagnosisDD/ Staphylococcus skin scalded syndrome

    -Impetigo

    -Pemfigus bulosa

    Working DiagnosisDD/ Staphylococcus skin scalded syndrome

    Treatment

    Total fluid required 60 ml/kg BW/dayParenteral None

    Enteral Breast Milk Diet / breast milk substitute :16 ml/2 hours/oralInj Neo K 1mg/IM (single dose)Gentamicin Eyedrop 1x1 gtt ODSChange pampersUmbilical cord treatment with steril gauze

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    Th

    eory

    the case mainly ininfants andchildren

    Pa

    tient

    Patient categorizedas infant

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    Theoryerythema initially withformation of large superficial

    localized blisters togeneralized exfoliation of thewhole body.

    They form large superficial

    thin formed bullae whichrupture and leave denudedskin behind after oozing fluidwhich varies from thin, serousliquid to purulent pus.

    They are more common

    around the extremities in theolder children and in theperiumbilical area in theneonates.

    Patientskin lesion initially appearedas redness patches and tender

    on his upper lips.

    Then this patch develops fluidblister and white membraneformed on lower lips. The

    lesion spread to the hand, legand abdomen.

    Within 2 days almost of hisbody was affected.

    Some of the blisters had

    ruptured, there wasdesquamation of the skin, andlarge, fragile, the blisters easilyruptured on the slightestpressure.

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    Theory

    A biopsy of the blister is one ofthe most definitive diagnostictests in SSSS.

    However, this is not alwayspossible due to limited availability

    of the tests and the timeconsuming factor.

    So, the diagnosis is often clinicaland confirmation is made afterfavorable response to anti-staphylococcal medicationss

    Patient

    Supportive examinations revealedleucocytosis.

    The culture result from the fluidblister pending.

    Based on the physical

    examination the diagnosis ofStaphylococcal Scalded SkinSyndrome (SSSS) was established

    Treated initially with Ceftazidime155mg two times daily injectionsand Gentamicin injections 16mgper 36hours.

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    TheoryThe differential diagnosisof the described

    exfoliative skin lesions inneonates includes

    staphylococcal scalded-

    skin syndrome (SSSS)

    bullous impetigo (BI)

    drug-induced toxicepidermal necrolysis

    epidermolysis bullosabullous mastocytosis

    neonatal pemphigus

    Patientdd/

    -Staphylococcus SkinScalded

    -Impetigo

    -Pemfigus bulosa

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    TheoryThe differential diagnosisof the described

    exfoliative skin lesions inneonates includes

    staphylococcal scalded-

    skin syndrome (SSSS)

    bullous impetigo (BI)

    drug-induced toxicepidermal necrolysis

    epidermolysis bullosabullous mastocytosis

    neonatal pemphigus

    Patientdd/

    -Staphylococcus SkinScalded

    -Impetigo

    -Pemfigus bulosa

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    Theory

    Management of SSSS isprimarily supportive

    with careful monitoringof electrolyte levelsbecause of the potentialfluid shifts across thedenuded skin.

    Intravenous antibiotics

    are administered todecrease thestaphylococcal burden.

    Patient

    Ceftazidime 155mg twotimes daily injections

    and Gentamicininjections 16mg per36hours.

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    t\


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